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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 15001 Commercial Street Lathrop/95330 to <br /> JOB ADDRESS CITY/ZIP m <br /> Acaderry Drive n <br /> APN PARCEL SIZE LA <br /> CROSS STREET NO USE PPLICATION# a <br /> OWNER NAME Banta School District PHONE 209-229-4650 H <br /> 22345 El Rancho Road Trey, CA 95304 <br /> OWNER ADDRESS CITYISTATEIZIP <br /> CONTRACTOR GEO-Ex- Subsurface E::ploration ONE 916-799-8199 <br /> CONTRACTOR ADDRESS 1510 Madera Drive CITYISTATE/IJP ,U lxon, CA 95620 <br /> PHONE <br /> SUBCONTRACTOR <br /> ENGEO, Inc. / 925-570-4056 <br /> 17273 Golden Valley Parkway Lathrop, CA 95330 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/Lr <br /> LICENSE XC-57 C-61 D-09 Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: eneral Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic nvate Irrigation/Agricultural Industrial Water Quality on'toring X Soil Sampling/Characterization <br /> Public Wal System <br /> II Glfeiem ham wrier Water System Name Contact Name or Pnone Number <br /> TYPE OF WORK New Well eplacement Well ' Well APeration/Modifcalion X.Other CPT <br /> Monitoring Wells) #of wells U Soil Bonng(s) #of honngs Geotechnical - "Or bU1ny5 <br /> Out-Of-Service Well Ci Out-Of-Service Well Re wal Cross-Connection Repair <br /> New Pum Pum lacement r,Pum Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air RotaryAuger Cable Tool Push Point Other C - <br /> Proposed Well Depth It Excavati in diamele/ Open Bottom �Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diam r / Conductor C sing Depth fl <br /> Well Casing Diameter_in Thickness/Gauge/AS Sched Steel . Plastic C Stainless Steel Other <br /> Grout Seal Depth it Neat Cement( Ib bag/5-/0 gal water) Sand Cement sack mra/7 gal Water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall X Other Tjco i.e Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions.Width fl ngth I Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set It Standing Water Level It <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND AT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR(NNSSPE/ICTI,rONS-PLEASE CALL(209)953-7697 <br /> SIGNED —!' ` TITLE „I,ZCJ( /.mak DATE 5 �c <br /> D E P A R T M E N T U S E O N L Y <br /> Application Acc Zed By Dale Area Employee ID# <br /> Grout Inspection By Date SPECIAL WCII Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#1 Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> EN043-05--4114116 WELL/PUMP PERMIT <br />